[House Report 114-696]
[From the U.S. Government Publishing Office]
114th Congress } { Rept. 114-696
HOUSE OF REPRESENTATIVES
2d Session } { Part 1
======================================================================
CONTINUING ACCESS TO HOSPITALS ACT OF 2016
_______
July 21, 2016.--Ordered to be printed
_______
Mr. Brady of Texas, from the Committee on Ways and Means, submitted the
following
R E P O R T
[To accompany H.R. 5613]
[Including cost estimate of the Congressional Budget Office]
The Committee on Ways and Means, to whom was referred the
bill (H.R. 5613) to provide for the extension of the
enforcement instruction on supervision requirements for
outpatient therapeutic services in critical access and small
rural hospitals through 2016, having considered the same,
report favorably thereon with an amendment and recommend that
the bill as amended do pass.
CONTENTS
Page
I. SUMMARY AND BACKGROUND............................................2
A. PURPOSE AND SUMMARY................................... 2
B. BACKGROUND AND NEED FOR LEGISLATION................... 2
C. LEGISLATIVE HISTORY................................... 3
II. EXPLANATION OF THE BILL...........................................3
III.VOTES OF THE COMMITTEE............................................4
IV. BUDGET EFFECTS OF THE BILL........................................4
A. Committee Estimate of Budgetary Effects............... 4
B. Statement Regarding New Budget Authority and Tax
Expenditures Budget Authority........................ 4
C. Cost Estimate Prepared by the Congressional Budget
Office............................................... 4
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE........5
A. Committee Oversight Findings and Recommendations...... 5
B. Statement of General Performance Goals and Objectives. 6
C. Information Relating to Unfunded Mandates............. 6
D. Congressional Earmarks, Limited Tax Benefits, and
Limited Tariff Benefits.............................. 6
E. Duplication of Federal Programs....................... 6
F. Disclosure of Directed Rule Makings................... 6
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED.............7
A. Text of Existing Law Amended or Repealed by the Bill,
as Reported.......................................... 7
B. Changes in Existing Law Proposed by the Bill, as
Reported............................................. 7
The amendment is as follows:
Strike all after the enactment clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Continuing Access to Hospitals Act of
2016'' or the ``CAH Act of 2016''.
SEC. 2. EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION
REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN
CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH
2016.
Section 1 of Public Law 113-198, as amended by section 1 of Public
Law 114-112, is amended--
(1) in the heading, by striking ``2014 and 2015'' and
inserting ``2016''; and
(2) by striking ``and 2015'' and inserting ``, 2015, and
2016''.
SEC. 3. REPORT.
Not later than one year after the date of the enactment of this Act,
the Medicare Payment Advisory Commission (established under section
1805 of the Social Security Act (42 U.S.C. 1395b-6)) shall submit to
Congress a report analyzing the effect of the extension of the
enforcement instruction under section 1 of Public Law 113-198, as
amended by section 1 of Public Law 114-112 and section 2 of this Act,
on the access to health care by Medicare beneficiaries and on the
quality of health care furnished to such beneficiaries.
I. SUMMARY AND BACKGROUND
A. Purpose and Summary
The bill, H.R. 5613, the ``Continuing Access to Hospitals
Act of 2016'' (``CAH''), as reported by the Committee on Ways
and Means on July 7, 2016, requires the department of Health
and Human Services to continue to instruct Medicare contractors
not to enforce requirements for direct physician supervision of
outpatient therapeutic services in critical access and small
rural hospitals through 2016.
B. Background and Need for Legislation
On July 1, 2016, Representative Jenkins (R-KS) and
Representative Loebsack (D-IA) introduced H.R. 5613, to provide
regulatory relief to Critical Access Hospitals (CAHs) by
temporarily prohibiting the Secretary from enforcing the
physician supervision requirement.
The Centers for Medicare & Medicaid Services (CMS)
finalized its regulation requiring direct physician supervision
in November 2009. Direct supervision, as defined by 42 Code of
Federal Regulations (CFR) 410.32, means that a physician or
non-physician practitioner must be immediately available to
furnish assistance and direction throughout the performance of
a procedure. In its manuals, CMS defines services and supplies
in which the direct supervision requirement applies as those
non-diagnostic therapeutic services including: clinical
services, emergency room services and observation services.
CMS initially proposed to enforce the direct physician
supervision requirement, where it would ensure CAHs were in
compliance, beginning January 1, 2014. However, Congress acted
separately in 2014 and 2015 to override enforcement of the
requirement. Congress has previously acted, and continues to
act with this bill, because we are concerned that such
stringent regulatory requirements may threaten access to care
for beneficiaries in rural areas. The CAH Act would continue
temporary relief from enforcement of the requirement for 2016.
C. Legislative History
Background
H.R. 5613 was introduced on July 1, 2016, and was referred
to the Committee on Energy and Commerce and additionally to the
Committee on Ways and Means.
Committee hearings
On July 28, 2015, the Committee on Ways and Means
Subcommittee on Health held a hearing on the status of rural
health for Medicare beneficiaries and highlighted Member
priorities.
On June 8, 2016, the Committee on Ways and Means
Subcommittee on Health held a Member day hearing on issues in
the Medicare program, including CAH issues.
Committee action
The Committee on Ways and Means marked up H.R. 5613, the
CAH Act on July 7, 2016, and ordered the bill favorably
reported to the House of Representatives as amended by a voice
vote (with a quorum being present).
In addition to the amendment in the nature of the
substitute to H.R. 5613 that was favorably reported, the
Committee on Ways and Means also favorably reported out an
amendment by Mr. Becerra to the amendment in the nature of a
substitute, which added a study by the Medicare Payment
Advisory Commission to analyze the effect of delaying the
enforcement of the physician supervision requirement on access
to, and quality of, health care for Medicare beneficiaries.
II. EXPLANATION OF THE BILL
Continuing Access to Hospitals Act of 2016
PRESENT LAW
Under current law, the CMS is enforcing its regulations,
where CAHs are required to provide for the direct supervision,
by a physician or non-physician practitioner, over delivery of
outpatient services.
REASONS FOR CHANGE
Congress acted separately in 2014 (P.L. 113-198) and 2015
(P.L. 114-112) to override the enforcement of the requirement.
Congress has previously acted, and continues to act with this
bill, out of concern that these regulatory requirements may
threaten access to care for beneficiaries in rural areas.
CAHs have reported uncertainty in the interpretation of
``immediately available'' and wide variation in CMS enforcement
of the definition. Additionally, CAHs have reported uncertainty
in the definition of ``clinical services'' that would be
covered by the direct supervision rule.
EXPLANATION OF PROVISION
The legislation prohibits the Secretary from enforcing the
direct supervision regulations under 42 CFR 410.27 for calendar
year 2016. 42 CFR 410.27 requires that services and supplies,
furnished in Critical Access Hospitals (CAHs), that assist
clinicians in the treatment of patients must be provided with
direct physician supervision.
EFFECTIVE DATE
The CAH Act would continue temporary relief from
enforcement of the requirement for 2016.
III. VOTES OF THE COMMITTEE
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, the following statement is made
concerning the vote of the Committee on Ways and Means in its
consideration of H.R. 5613, the ``Continuing Access to
Hospitals Act of 2016,'' (``CAH'') on July 7, 2016.
The Chairman's amendment in the nature of a substitute was
adopted by a voice vote (with a quorum being present).
The amendment by Mr. Becerra to the amendment in the nature
of the substitute to H.R. 5613, which added a study by the
Medicare Payment Advisory Commission to analyze the effect of
delaying the enforcement of the physician supervision
requirement, was agreed to by a voice vote (with a quorum being
present).
The bill, H.R. 5613, was ordered favorably reported as
amended by voice vote (with a quorum being present).
IV. BUDGET EFFECTS OF THE BILL
A. Committee Estimate of Budgetary Effects
In compliance with clause 3(d) of rule XIII of the Rules of
the House of Representatives, the following statement is made
concerning the effects on the budget of the bill, H.R. 5613, as
reported. The Committee agrees with the estimate prepared by
the Congressional Budget Office (CBO), which is included below.
B. Statement Regarding New Budget Authority and Tax Expenditures Budget
Authority
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee states that the
bill involves no new or increased budget authority. The
Committee states further that the bill involves no new or
increased tax expenditures.
C. Cost Estimate Prepared by the Congressional Budget Office
In compliance with clause 3(c)(3) of rule XIII of the Rules
of the House of Representatives, requiring a cost estimate
prepared by the CBO, the following statement by CBO is
provided.
U.S. Congress,
Congressional Budget Office,
Washington, DC, July 20, 2016.
Hon. Kevin Brady,
Chairman, Committee on Ways and Means,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 5613, the
Continuing Access to Hospitals Act of 2016.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lori Housman.
Sincerely,
Theresa Gullo
(For Keith Hall, Director).
Enclosure.
H.R. 5613--Continuing Access to Hospitals Act of 2016
H.R. 5613 would require the Secretary of Health and Human
Services to continue to apply an exception to the requirement
that certain outpatient therapeutic services be provided under
the direct supervision of a physician when they are furnished
in critical access and small rural hospitals. This exception
would apply through calendar year 2016. The Centers for
Medicare and Medicaid Services (CMS) currently does not enforce
the federal requirement related to direct supervision for those
services and CBO does not anticipate that CMS will begin
enforcing the requirement in the near future under current law.
(Those services are subject to supervision requirements
established under state laws.)
Because CBO expects that H.R. 5613 would not change how CMS
enforces the direct supervision requirement, we estimate that
enacting H.R. 5613 would not affect direct spending or
revenues; therefore, pay-as-you-go procedures do not apply.
Additionally, CBO estimates that enacting H.R. 5613 would not
increase net direct spending or on-budget deficits in any of
the four consecutive 10-year periods beginning in 2027.
H.R. 5613 would require the Medicare Payment Advisory
Commission to analyze and report to Congress on how enforcing
the requirement for direct supervision would affect health care
provided to beneficiaries. CBO estimates that the cost of this
study would be less than $500,000; that spending would be
subject to the availability of appropriated funds.
The bill would not impose intergovernmental or private-
sector mandates as defined in the Unfunded Mandates Reform Act
and would impose no costs on state, local, or tribal
governments.
The CBO staff contact for this estimate is Lori Housman.
The estimate was approved by Holly Harvey, Deputy Assistant
Director for Budget Analysis.
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE
A. Committee Oversight Findings and Recommendations
With respect to clause 3(c)(1) of rule XIII of the Rules of
the House of Representatives, the Committee advises that the
findings and recommendations of the Committee, based on
oversight activities under clause 2(b)(1) of rule X of the
Rules of the House of Representatives, are incorporated in the
descriptive portions of this report. Statement of General
Performance Goals and Objectives.
B. Statement of General Performance Goals and Objectives
With respect to clause 3(c)(4) of rule XIII of the Rules of
the House of Representatives, the Committee advises that the
bill contains no measure that authorizes funding, so no
statement of general performance goals and objectives for which
any measure authorizes funding is required.
C. Information Relating to Unfunded Mandates
This information is provided in accordance with section 423
of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104-
4).
The Committee has determined that the bill does not contain
Federal mandates on the private sector. The Committee has
determined that the bill does not impose a Federal
intergovernmental mandate on State, local, or tribal
governments.
D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff
Benefits
With respect to clause 9 of rule XXI of the Rules of the
House of Representatives, the Committee has carefully reviewed
the provisions of the bill, and states that the provisions of
the bill do not contain any congressional earmarks, limited tax
benefits, or limited tariff benefits within the meaning of the
rule.
E. Duplication of Federal Programs
In compliance with Sec. 3(g)(2) of H. Res. 5 (114th
Congress), the Committee states that no provision of the bill
establishes or reauthorizes: (1) a program of the Federal
Government known to be duplicative of another Federal program;
(2) a program included in any report from the Government
Accountability Office to Congress pursuant to section 21 of
Public Law 111-139; or (3) a program related to a program
identified in the most recent Catalog of Federal Domestic
Assistance, published pursuant to the Federal Program
Information Act (Pub. L. No. 95-220, as amended by Pub. L. No.
98-169).
F. Disclosure of Directed Rule Makings
In compliance with Sec. 3(i) of H. Res. 5 (114th Congress),
the following statement is made concerning directed rule
makings: The Committee estimates that the bill requires no
directed rule makings within the meaning of such section.
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED
A. Text of Existing Law Amended or Repealed by the Bill, as Reported
In compliance with clause 3(e)(1)(A) of rule XIII of the
Rules of the House of Representatives, the text of each section
proposed to be amended or repealed by the bill, as reported, is
shown below:
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e)(1)(A) of rule XIII of the
Rules of the House of Representatives, the text of each section
proposed to be amended or repealed by the bill, as reported, is
shown below:
PUBLIC LAW 113-198
* * * * * * *
SECTION 1. EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION
REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN
CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH
2014 AND 2015.
The Secretary of Health and Human Services shall continue to
apply through calendar years 2014 and 2015 the enforcement
instruction described in the notice of the Centers for Medicare
& Medicaid Services entitled ``Enforcement Instruction on
Supervision Requirements for Outpatient Therapeutic Services in
Critical Access and Small Rural Hospitals for CY 2013'', dated
November 1, 2012 (providing for an exception to the restatement
and clarification under the final rulemaking changes to the
Medicare hospital outpatient prospective payment system and
calendar year 2009 payment rates (published in the Federal
Register on November 18, 2008, 73 Fed. Reg. 68702 through
68704) with respect to requirements for direct supervision by
physicians for therapeutic hospital outpatient services).
* * * * * * *
B. Changes in Existing Law Proposed by the Bill, as Reported
In compliance with clause 3(e)(1)(B) of rule XIII of the
Rules of the House of Representatives, changes in existing law
proposed by the bill, as reported, are shown as follows
(existing law proposed to be omitted is enclosed in black
brackets, new matter is printed in italics, existing law in
which no change is proposed is shown in roman):
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e)(1)(B) of rule XIII of the
Rules of the House of Representatives, changes in existing law
proposed by the bill, as reported, are shown as follows (new
matter is printed in italics and existing law in which no
change is proposed is shown in roman):
PUBLIC LAW 113-198
* * * * * * *
SECTION 1. EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION
REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN
CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH
[2014 AND 2015] 2016.
The Secretary of Health and Human Services shall continue to
apply through calendar years 2014 [and 2015], 2015, and 2016
the enforcement instruction described in the notice of the
Centers for Medicare & Medicaid Services entitled ``Enforcement
Instruction on Supervision Requirements for Outpatient
Therapeutic Services in Critical Access and Small Rural
Hospitals for CY 2013'', dated November 1, 2012 (providing for
an exception to the restatement and clarification under the
final rulemaking changes to the Medicare hospital outpatient
prospective payment system and calendar year 2009 payment rates
(published in the Federal Register on November 18, 2008, 73
Fed. Reg. 68702 through 68704) with respect to requirements for
direct supervision by physicians for therapeutic hospital
outpatient services).
* * * * * * *
[all]